Provider Demographics
NPI:1598940835
Name:MORENO-LOFGREN, MELBA A (SLP)
Entity Type:Individual
Prefix:
First Name:MELBA
Middle Name:A
Last Name:MORENO-LOFGREN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 SARALVO RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-5780
Mailing Address - Country:US
Mailing Address - Phone:817-913-4107
Mailing Address - Fax:
Practice Address - Street 1:3840 HULEN ST STE 100
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7269
Practice Address - Country:US
Practice Address - Phone:817-569-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-06
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193433302Medicaid
TX8T7491OtherBLUE CROSS BLUE SHIELD TX